Persistence of monkeypox virus at oral and rectal sites – Authors' reply
Authors: Hasti Jalalzadeh, Hannah Groenen, Niels Wolfhagen, Marja A Boermeester
Journal: The Lancet Microbe (2023)

We thank colleagues Pruijn and Dorrestijn for their comments. Pruijn and Dorrestijn are concerned that our network meta-analysis is not generalisable to all surgical procedures, specifically to shoulder surgery. As a main response, we must stipulate that the pathophysiology of wound infections is similar among various types of surgery and implant surgery and overall data need to be considered instead of underpowered and low-grade evidence per surgical procedure or surgical site. Microorganisms might differ per site but the mechanism by which a skin antiseptic should work on decreasing microbial load at the surgical site is comparable. Low-grade infections in shoulder surgery are a rare but devastating long-term complication. Unfortunately, data on skin antiseptics with long-term follow-up are scarce and therefore long-term outcome is outside of the scope of our study. A current network meta-analysis aims to evaluate effects of skin antiseptics in clinical practice. The study by Dörfel and colleagues1Dorfel D Maiwald M Daeschlein G et al.Comparison of the antimicrobial efficacy of povidone-iodine-alcohol versus chlorhexidine-alcohol for surgical skin preparation on the aerobic and anaerobic skin flora of the shoulder region.Antimicrob Resist Infect Control. 2021; 10: 17Crossref PubMed Scopus (12) Google Scholar concerns a non-clinical analysis of healthy volunteers and therefore does not substantiate any clinical evidence for clinical outcomes after shoulder surgery. Similarly, the proposed skin antiseptics, benzoyl peroxide and hydrogen peroxide, are investigated in culture studies as an addition to chlorhexidine,2Stull JD Nicholson TA Davis DE Namdari S Addition of 3% hydrogen peroxide to standard skin preparation reduces Cutibacterium acnes-positive culture rate in shoulder surgery: a prospective randomized controlled trial.J Shoulder Elbow Surg. 2020; 29: 212-216Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar as an application of the antiseptic outside the operating theatre,3Kolakowski L Lai JK Duvall GT et al.Neer Award 2018: benzoyl peroxide effectively decreases preoperative Cutibacterium acnes shoulder burden: a prospective randomized controlled trial.J Shoulder Elb Surg. 2018; 27: 1539-1544Summary Full Text Full Text PDF PubMed Scopus (60) Google Scholar or in healthy volunteers.4Scheer VM Jungestrom MB Lerm M Serrander L Kalen A Topical benzoyl peroxide application on the shoulder reduces Propionibacterium acnes: a randomized study.J Shoulder Elb Surg. 2018; 27: 957-961Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar We find evidence from these studies impossible to translate into clinical settings and infection rates, and therefore we find that they have no place in any recommendation concerning shoulder surgery or any other type of surgery. In our network meta-analysis, we have included one randomised controlled trial5Saltzman MD Nuber GW Gryzlo SM Marecek GS Koh JL Efficacy of surgical preparation solutions in shoulder surgery.J Bone Joint Surg Am. 2009; 91: 1949-1953Crossref PubMed Scopus (232) Google Scholar that compared iodine–alcohol with chlorhexidine–alcohol in shoulder surgery with a follow-up of at least 10 months. Some years have passed since the publication of that trial and, if available, long-term follow-up data might add specific data on the prevention of low-grade infections after shoulder surgery. Other than that, we must look at high-quality and high-level evidence data in surgery instead of niche data. We declare no competing interests. Preventive surgical site strategies should be site specificThe systematic review by Hasti Jalalzadeh and colleagues1 on the efficacy of different preoperative skin antiseptics for the prevention of surgical site infections (SSIs) concluded that skin preparation with 2·0–2·5% chlorhexidine in alcohol or 1·5% olanexidine is most effective. However, the human skin is colonised by a diverse milieu of microorganisms that is highly variable depending on topographical location. This diversity in skin bacteria leads to different causative agents for SSIs, dependent on the surgical site. Full-Text PDF Open Access